Comparative Study of Parathyroid Identification Techniques Using Zuckerkandl's Tubercle Versus Parathyroid Arterial Supply as Intra-Operative Markers.

Thyroid surgeons should be able to identify factors that prevent parathyroid damage. The aim of the study was (i) to compare the effectiveness of using Zuckerkandl's Tubercle (ZT) versus superior thyroid artery (STA) and inferior parathyroid artery (ITA) as markers for identification of superior and inferior parathyroid glands and (ii) to demonstrate a series of detailed, logical and orderly operative steps to identify ZT during thyroidectomy operation. This 1-year prospective observational study was carried out in the Department of Otolaryngology in a tertiary medical institute. Out of 36 cases of thyroidectomy, parathyroid identification in Group A was based on STA and ITA and in Group B was based on ZT. The surgical steps, parathyroid location, preservation and its anatomical relations were noted. The mean age in Group A and Group B was 38.8 years and 44.9 years respectively with 77.4 and 62.5% SPT identified above the intersection of RLN and ITA respectively. On left side 62.5% SPT were  located at 2 o'clock position and 50% at 10 o'clock location in right side. In Group A, 60.7% of IPT glands were related close to ITA while in Group B it was 44.4%. Group B reported a higher rate of successful identification and preservation (93.75%). ZT greatly improved the reliability for localising and preserving the parathyroid glands during thyroidectomy. SPT is usually found to lie cranial to ZT, above the intersection of RLN & ITA and behind RLN whereas IPT is variable and lies below the intersection.

Proactive exploration of inferior parathyroid gland using a novel meticulous thyrothymic ligament dissection technique.

INTRODUCTION: The inferior parathyroid gland (IPTG) is widely distributed; effective techniques for its safe exploration and protection during thyroid surgery have not been documented. The thyrothymic ligament (TTL) is a connective tissue located between the thymic tongue and thyroid. This study aims to introduce a novel meticulous thyrothymic ligament dissection technique and assess its role in proactive exploration and situ preservation of IPTG. MATERIALS AND METHODS: 737 patients undergoing initial thyroid surgery between 2017 and 2021 in the Department of General Surgery of the First Affiliated Hospital of Nanjing Medical University were retrospectively recruited for this clinical study. In 391 of the recruited patients, the TTL was dissected, and the number and location of IPTG were recorded. Among them, 214 patients underwent total/near-total thyroidectomy (TT) plus central neck dissection (CND) were assigned to the observation group. The control group included 346 consecutive patients who underwent conventional TT plus CND. After 1:1 propensity score matching, each group contained 206 patients. The incidence of postoperative hypoparathyroidism was recorded. RESULTS: Among the 391 patients, 596 sides were dissected, out of which 436 sides (73.2%) had TTL, and approximately 90.1% of IPTG were located and identified. A statistically significant difference in incidence of temporary (27.7 vs. 49.0%, P < 0.001) and permanent hypoparathyroidism (0 vs. 8.2%, P = 0.047) was noted between the observation group and the control group. CONCLUSION: The meticulous thyrothymic ligament dissection technique helps to protect IPTG in situ and reduce the incidence of postoperative hypoparathyroidism.

An improved method of searching inferior parathyroid gland for the patients with papillary thyroid carcinoma based on a retrospective study.

Objective: Many surgeons knew the importance of parathyroid gland (PG) in the thyroid surgery, but it was even more difficult to be protected. This study aimed at evaluating the effectiveness of the improved method of searching inferior parathyroid gland (IPG). Methods: 213 patients were enrolled and divided into test and control groups according to different methods of searching IPG in the surgery. Consequently, we compared the surgical outcome parameters between the two groups, including the operative time, numbers of PG identifying (PG protection in situ, PG auto-transplantation, and PG accidental removal), numbers of the total lymph node (LN) and metastatic LN, parathyroid hormone (PTH), transient hypoparathyroidism, transient recurrent laryngeal nerve palsy, and postoperative bleeding. Results: We identified 194 (194/196, 98.98%) and 215 (215/230, 93.48%) PGs in the test group and control group, respectively, and there was a significant difference (P = 0.005), and this result was due to IPG identification differences (96/98, 97.96% vs. 100/115, 86.96%, P = 0.004). Meanwhile, there was a lower ratio of IPG auto-transplantation in the test group compared with that in the control group (46.94% vs. 64.35%, P = 0.013). Serum PTH one day after the operation was 3.65 ± 1.86 vs. 2.96 ± 1.64 (P = 0.043) but with no difference at 6 months. There were no differences in metastatic LN and recurrent laryngeal nerve palsy between two groups. Conclusion: The improved method of searching IPG was simple, efficient, and safe, which was easy to be implemented for searching IPG and protecting it well.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury.

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury.